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. v Environmental Health Department <br /> UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 3 sets of plans & applications as originals will be retained by EHD ) <br /> 1 . Site map enclosed ? YES [ NO [ ] <br /> 2 . Submit copies of ICC Service Technician and/or Installer' s certificate and all manufacturer training <br /> certificates for each person installing or testing any component that is repaired or replaced . Ensure a copy of <br /> the "Site Health and Safety Plan" is available on the jobsite as required by Title 8 . <br /> 3 . Detailed description of work to be completed . List components to be repaired or replaced and attach a <br /> diagram drawn to scale showing location of repairs and/or replacements . If repairing a component , describe <br /> how this will be done , ( If adding piping , UDC' s , or other UST equipment , or performing tank top upgrade , <br /> use the UST Installation Application pages 4- 8 as necessary for a timely plan review) : <br /> GH.4A/ 4C - Our � -frrc6 /ohG 1f E2:0 e .. nWDTIC? /n, - C / 11 bok <br /> «, � ro�p "t�u(De fo � elow 9S °�p � <br /> 4, List of equipment to be used (Attach manufacturer' s specification sheets showing third-party approval ) : <br /> '7 —/neA leiiag ky cli, Sche4tle, 40 a e. _ <br /> 5 . Decontamination Procedures : <br /> a . Will piping be decontaminated prior to removal ? YES [ ] NOK <br /> b . Identify contractor performing decontamination : <br /> Name _ � eyg 772 ,41n Z /U c, Phone (�OJ`) 1,)59 <br /> Address 27 5 1'Nc2t)/ Al A vei , G(,y/� � City ViFl✓ rajgA Zip 4930D3 <br /> 3of6 <br />